ASSI Monograph Safe Spine Surgery Shankar Acharya, Amit Jhala, Amol Rege, Pankaj Kandwal
Page numbers followed by ‘f’ figure; and ‘t’ indicate table respectively.
Abandonment 113
Acetaminophen 82
in children 82
Acute respiratory distress syndrome 58
Additive manufacturing 52
Advanced trauma life support 127
Alcohol consumption 100
American College of Cardiology 103
American Heart Association 103
American Society of Anesthesiologists 3, 5, 72
Analgesia, controlled 82
Anesthesia team assists 77
Anesthetic agents 33
in intraoperative
neuromonitoring 36
Anesthetic safety 77
Anesthetic, short-acting 82
Anesthetic team 37
Animal model study 34
Antibiotic prophylaxis 79, 82, 132
Anticoagulant drugs 3
use of 25
Anticoagulation 60
Antidiabetic medication 60
Anxiety 26
Arterial bleeding, massive 133
Arteriovenous malformations 34
Association of Spine Surgeons of India 11
Atelectasis 61
Atrial fibrillation 25
Autoclaving 132
Babinski's reflex bilaterally 139
Basilar invagination 133
Behavioral health 91
Biopsy specimen 128
Bisphosphonates 63
Blood loss 10, 37, 57, 63
excess 12
Blood management 82
Blood pressure 100, 138
changes in 37
control 77
Blood sugar 100
Blood supply to pedicle 49
Blood vessels 78
Body mass index 5, 62
Bone density 60
Bone graft 64
and neuromonitoring 11
impacted L2-l3 disc space 131f
Bone quality, assessment of 28
Bone removal 48
Bowel movements 102
Bradycardia, sudden 38
Briefing and debriefing 122
Burst fracture 127
Calcitonin 63
Canal diameter 47
Cardiac complications 58
Cardiac examination, in-depth 29
Catheters and drains 82
Cell savers, use of 63
Cement augmentation 65
Central line-associated bloodstream infection 114
Central nervous system 135
Central spinal tuberculosis 129
Cerebral palsy 72, 73
Cervical and lumbar spinal fusions 104
Cervical laminectomy 49
Cervical spine bone tumor 52
current case 134f
Cervicomedullary junction 133, 133f
Charlson index 25
Cholecystitis 58
Cholelithiasis 72, 73
Clean-air environments 16
Clear roles and responsibilities 122
Cobb's angle 38
Cobbs, severe 137
Cold irrigation, use of 38
Column realignment, anterior 66
Common iliac vessels 93
Communication 110
content of 111
documentation of 111
honesty in 122
poor 117, 120
Complex adult spinal deformity 5767
correction 63
counseling and optimization 59
medical complications in 60
list of complications in 58t
safety in 57
undergoing 62
Complex spine surgery, integral part of 50
Compound muscle action potential 34, 36
Computer-assisted navigation 50
in litigation, value of 110
in telemedicine 110
informed 109
process, steps in 108f
proxy 109
real 109
special 109
withdrawal of 110
Constipation 82, 101
Consumables 108
Consumer Protection Act 114
Continuing medical education 5
Cord edema 128
Cord using epidural electrodes 34
Corpectomy 49
Corrective maneuvers 77
Cortex breach, check for 49
Cortical blindness 72, 73, 92
Counseling 110
content of 111
session 59, 60
sheets 110
Craniovertebral, cervical anomaly 133f
Craniovertebral junction 133, 133f, 134f
Crankshaft phenomenon 72
Crew resource management 117
Criminal negligence 114
Debridement 128f, 131
Decubitus ulcers 58
Deep infection 72, 73
Deep vein thrombosis 25, 58, 61, 73, 100
Deficiency in surgical skills 113
correction of 38, 40, 64, 80,
complex 52
Degenerative disc disease 93
Degenerative lumbar spine, stabilization for 104
Degenerative scoliosis 94
used for 53
Delirium 58
Dementia 26
Denial 113
Depression 26
diagnosis of 26
Diclofenac 102
Digital subtraction angiography 134, 134f
Disability-adjusted life years 116
Disaster management teams 119
Disc debridement 132
Disc degeneration 47
chronic 57
free proportion 57
underlying 1
Disseminated intravascular coagulation 58
Distal neurovascular examination 127
Dorsal column 34
of spinal cord 79
Dorsal roots 34
Dorsal spine anteroposterior 137f
Dual-energy X-ray absorptiometry 28, 60
Dural tears 58
Dysphagia 3
Ehlers-Danlos syndrome 72
Electrical equipment 17
Electroencephalography 34
Electrolyte stabilization 75
Electromyography 34, 35, 64
Electronic medical records 110
Electrophysical changes 80
Electrophysiological techniques 33
Embolism 61
Enhanced recovery after surgery 81, 98
begin 98
protocol 91, 99f
for spine surgery 99
Enteral feeding 61
Epidural abscess 130
Epidural analgesia 82
Epidural collection 130
Epidural hematoma 58
Equipment 108
Escalation of concern 118
graded assertiveness 121
European Quality of Life-5 Dimensions scores 26
Evidence-based best practices 108
Exacerbating pain 47
Expertise, field of 118t
Exponential refinements 9
Extensor digitorum brevis 40f
left 40
Facetectomies 40
Faster recovery 103
Fentanyl 36
Fluid resuscitation 135
Fluorodeoxyglucose 91
Focal pain 65
Food and Drug Administration 53
Foraminotomy 49
Foreign body after surgery 113
Fracture hematoma 128f
Fracture rods 140
Gabapentin 82
Gait imbalance 139
Gastric tubes 61
Gastrocsoleus 38
GeneXpert 129
detected 128
Giddiness 102
Graft failure 58
Had gait unsteadiness 42
Halogenated anesthetic agents 36
Halothane 33
Hardware fatigue 24
Harrington instrumentation 33
Healthcare-associated infections 114
Healthcare professionals 6
Healthcare, spheres of 16
Healthcare system 89
Health-related quality of life 62
Hematoma 128
Hemivertebra 74f
posterior 139
T8 38
Hemoglobin 37
levels 10, 63
Hemothorax 136, 138
Hepatitis B surface antigen negative 21
positive 21
Hepatobiliary disorders 75
Herniated L5-S1 disc 125
removal of 126f
Herniated soft lumbar disc 125
Hip surgeon 51
Hospital-acquired condition 114
Hospital-acquired injuries 114
Hospitals, modern-day 16
Human errors 14
Human life expectancy 57
Hypertension 25
Hypoglycemic drug 21
Idiopathic scoliosis 38, 72, 73
Implant failure 62
leading 139
Implants, misplaced 64
Indian Medical Council 110
Indocyanine green angiography 135
Infection 25, 65, 79
chances of 100
Infectious Diseases Society of
America 89
Infective spondylodiscitis, signs of 130
Informed consent, lack of 113
Infrastructure 16
inoculation 21t
risks of 36
Institute of Medicine 1
Instrumentation and logistics 17
levels 64
multilevel 131f
problem 65
removal of 36
Intensive care unit 61, 111
Interbody fusion, Mi-lateral approach for 66
International Classification of Diseases, modification 25
Intervertebral space level 125
Intoxicating agents, influence of 109
Intraspinal tumor excision 35
Intrathecal morphine 82
Japanese Orthopaedic Association 104
Joint Commission data of sentinel events 120
Judgment issues 113
Judgment, error of 113
Jurisdiction in spine surgery 112
Kerrison rongeur 48
Ketamine 36
Ketorolac 82
Kyphoscoliosis, congenital 75f
Kyphoscoliotic deformity 52f
Kyphosis 141
angle of 65
correction 77
good correction of 140f
junctional 72
proximal junctional 62, 64
proximally 65
short 64
Kyphotic deformity 133
inferior part of 126f
superior 126f
Laminar trap 126
chance of 126f
Laminectomy 49, 141
T10-L1 42
Laminoplasty 49
for myelopathy 104
Language barrier 36
Laparoscopic cholecystectomy 116
Lateral lumbar interbody fusion 66
Lemniscal system 34
Lethal pulmonary complications 61
Light-emitting diodes 51
Lumbar decompression 103, 104
Lumbar disc herniation 103
Lumbar interbody fusion 104
Lumbar lordosis 126f
Lumbar scoliosis 57
Lumbar spine 93
Lumbosacral spine 125
radiographs of 130, 130f
scan of
Lung injury, acute 58
Malignancy 90
presence of 25
Marfan syndrome 72
Maslach Burnout Inventory 117
McCulloch laminar trap, reason for 126f
McCulloch retractor 125
proper placement of 126f
Mean arterial pressure 77, 92
Mechanical errors 3
Medical accidents 113
Medical comorbid conditions 10
Medical errors 1, 2
Medical issues, 66 112
Medical negligence 113
Medical practice, complications and deaths 107
Medical records confidentiality of 111
legibility of 110
Medical Research Council 139
Medication charts 110
Medication lists 28
Medicolegal cases 110
Medicolegal issues 114
Medicolegal requirements 108
Metacognition 117, 118, 120
Metacognitive strategies 120
Metastatic spinal disease 90
Microdiscectomy 103, 125
Military crew resource management 59
Military decision-making process 119
Military speak 120
Mini open anterior lumbar interbody fusion 66
Minimally invasive deformity, first-generation 66
Minimally invasive spine surgery 57, 67, 98
role of 66
Modern technology, cost risk analysis of 53
Molecular diagnostic tests 129
Motor evoked potential 33, 34, 35, 79
baseline end of surgery 43f
good baseline 39f, 40f, 41f
loss of 39f, 40f, 41f
monitoring 64
quadriceps and external anal sphincters 42f
recording end of surgery 39f, 40f, 41f
response during surgery 42f
Mucopolysaccharidoses 72
Multidisciplinary team 88
approach to spine surgery 88
for specific pathologies 89
role of 88
value of second opinion 89
Multiple small amplitude signals 34
Muscular dystrophies 72
Mycobacterium tuberculosis complex 128
Myelomeningocele 72
Myocardial infarction 25
National Acute Spinal Cord Injury Study 38
National Early Warning Score 19t
clinical escalation pathway 20t
Naturalistic decision-making 119
Nausea prevention 82
Navigation 17, 80
and robotics 50
Naviport integration 50, 51
Neck disability index 62
Nerve injury 113
Nerve paralysis 2
Nerve root 33, 78 mechanical irritation 38
Neural injury 64
Neural structures 37
changes 80
complications 73, 79
injuries 72
monitoring 79
Neurological deficit 39, 43, 64, 65, 141
in early-onset scoliosis 139
Neurological injury 92
Neuromodulatory medication 82
Neuromonitoring 11, 33
alerts in 37
false positive and false negative responses in 37
intraoperative 79
modalities of intraoperative
multimodality 43
signals, loss of 92
team 37
techniques 34, 35t
Neuromuscular blocking medications 80
Neuromuscular conditions 72
Neuromuscular disorders 82
Neurosurgery 91
for tumor removal 48
Neurosurgical procedures 33
Neurotonic discharge 36
Neurovascular compromise 50
Neurovascular structures 48
Nitric oxide 33
Nonidiopathic spine deformities 75
Nonsteroidal anti-inflammatory drugs 82
Nontechnical skills 117
enhancing safety in spine surgery 116
Normothermia 82
Nutritional assessment 100
Nutritional deficiency 75
Nutritional supplementation 100
based intraoperative CT navigation 49f
leads 50
spin 49f
Obesity 57, 61, 62
Occipitocervical fusion 134, 135f
Odontoidectomy 133
Operation theater 10, 108 antibiotic dressings in 66
Opioid medications 104
Optimum synchrony 108
Osteopenia 131f
Osteoporosis 3, 62
diagnose 62
Osteoporotic perimenopausal women 63
Osteoporotic spine, setting of 63
Osteotomy, site for 52f
Oswestry disability index 61
control 82
low back 116
chronic 89
Pancreatitis 72
Paracentral disc prolapse 120
Paralysis, complete 58, 64
Paramedian subperiosteal exposure 125
Paramedical staff, role of clinical nurse 94
operation theater staff 94
Pathological fracture 128f
Pediatric spine deformity 76
complications 72
encompasses 72
improving safety in 72
perioperative safety measures 77
populations prone to complications 73
postoperative safety measures 81
preoperative safety measures 75
surgery, complications in 73t
treatment of 72
Pediatric spine surgery 81
risk profile for 72
Pedicle fracture 58
Pedicle screws 49, 136
insertion techniques 78
Pedicular cuts 60
Percutaneous biopsy 131
Peripheral nerve, stimulation of 33
Peripheral nerve surgery 104
Piezoelectric device 48
Pleural effusion 61
Pneumatic calf pumps 102
Pneumatic compression devices 61
Pneumonia, incidence of 61
Pneumothorax 138
Polyetheretherketone cage, using 128f
Polytrauma 90
Positron emission tomography 91, 128
Propofol 36
Proximal junctional failure, cases of 64
Pruritus 82
Pseudarthrosis 24, 62, 72, 82, 100
Pseudomembranous colitis 58
Pseudomeningocele 131f
Psychiatric conditions 25
Psychiatric conditions, diagnoses of 26
Psychiatrist 94
Psychological conditions 25
Pulmonary complications 58, 73
Pulmonary embolism 25, 58
Pulmonary examination 29
Pyogenic spondylodiscitis, postoperative cases 130
Quadriceps 38
bilateral 42
Quality control systems 108
Quality improvements 59
Quantifying air quality, way of 16
Red flag signs 14
Reflex inhibition 102
Regulations/rules, lack of 9
Renal dysfunction 75
Renal failure 58
Respiratory depression 82
Respiratory failure 73
Retroperitoneal hemorrhage 58
Rigid robotic arm 50f
Robot-assisted spine surgery 81
Rod fracture, risk of 141
Rods, breakage of 140f
Root cause analysis 22
Rotary movements 48
Royal College of Radiologists 89
Safety protocols 16
governance 19
perioperative care 18
untoward intraoperative events 18
Scalp electrodes 34
Scheuermann kyphosis 72
Schizophrenia 26
congenital 38, 76f
early-onset 141
surgery for 34
treatment of 33
X-rays posteroanterior 137f
Scoliosis Research Society 33
morbidity and mortality database 64
Scoliosis Research Society questionnaire 61
Screw trajectory 52f
planning of 50f
Scrub nurse 12
Seattle Spine Team approach 91
protocol 27, 59
Segmental motion 47
Seizure disorders 73
Seroma formation 72
Shoulder balance 138f
Simultaneous surge in technology 46
Skeletal dysplasia 72
Skills 118
Soft disc compressing 125
Somatosensory cortex 34
Somatosensory evoked potential 34, 35, 64, 79
use of 33
Somnolence 82
Spasticity 42
Sphincters 40
Spinal ailments, diagnosis of 89
Spinal cord 33, 34, 78
function of 33
injury, complete 72
levels of 35
monitoring 57, 63
risk during instrumentation 77
Spinal cord evoked potentials 33
Spinal deformity 90, 140
complex 47
correction 88, 92
Spinal fusion, posterior 82
Spinal implants, spectrum of 11
Spinal infection multidisciplinary management project 91
Spinal infections 91, 89
Spinal injuries 90
Spinal instability, assessment of 47
Spinal motion, range of 132
Spinal pathology 98
Spinal surgery 33
modern-day 17
Spinal trauma 90
Spinal tuberculosis
case of 127
diagnosis of 129
masquerading burst fracture 127
Spinal tumors 34, 89
Spine adverse events severity score 5, 21, 22t
Spine anesthesia, complex 91
Spine checklist
complications 9
how to manage 14
intraoperative 11
postoperative 12
preoperative 9
Spine deformity 72
etiology 73
surgery for 82
Spine fusion 75
Spine pathology 48
Spine Protocol and Seattle Spine Team approach 22
Spine surgeons armamentarium of 53
caddy of hardware 49
encountering intraoperative complications 119
Spine surgery 14, 24, 29, 46, 107
advances in imaging 46
adverse events in 1
begins planning in 118
causes 3
checklist, point of 13f
common malpractice claims in 112
complex 91
essential components of consent in 108
incidence of 116
inherent complexity in 1
integral part of 94
neuromonitoring 33
multidisciplinary team approach 88f
practice of 89
prevalence 2
rates 116
risk factors of adverse events 5t
risk stratification in complex 24
safe, checklists 101
second opinion 89f
subspecialty 9
team approach 6
treatment outcome in 107f
undergoing 26
value of technology for safe 46
Spine, stable 81f
SpineMap Software 50
Spoliation 113
Spondylolisthesis, presence of 65
Standard nontechnical skills 118t
Standard operating practice 16
Standardized perioperative protocols 27
Staphylococcus aureus 130
Straight leg raise 125
evaluation and risk 27
preoperative risk 25
risk 24, 60
steps of risk 30
Stroke, postoperative risk of 25
Stryker spinal navigation 50
Stryker SpineMap tracker 51
Superficial infection 73
Superior mesenteric artery syndrome 72, 73
Surgeon leadership, role of 6
Surgeon's memory 3
high-risk 22
planning of 3
prevention 5
reporting of adverse events 4
risk factors for adverse events in 4
wrong level 113
Surgical checklist 6
Surgical procedure 3
Surgical protocol 5
Surgical site infection 62, 65
Surgical team 24
and hospitals to prevent adverse events 107
role of 91
anesthetist 92
physician 91
surgeon for anterior access 93
two surgeon approach 92f
to safeguard 108
Surgical technology and equipment 6
Syndrome of inappropriate antidiuretic hormone secretion 58
Syndromic scoliosis 136
inadvertent pleural tear in 136
Systematic weaknesses 58
Targeted fluid management 82
Teamwork and leadership 117
skills 122
Technical education curricula 117
Teriparatide 63
Thoracic spine 75f
Thoracolumbar burst fractures 128
Thoracolumbar interfacial plane block 101
Thoracolumbar junction (D12-L2) 128
Thromboembolic episode, incidence of 63
Thromboprophylaxis 3
Torque-counter-torque 11
Total intravenous anesthesia 36
Total leukocyte count 127
Tramadol infusions 102
Tramadol, usage of 102
Tranexamic acid 63, 78
infusion 102
Transcranial motor evoked potential 33, 64
Transforaminal lumbar interbody fusion 66, 104
Transient neurological deficits 58
Transoral odontoidectomy 135f
Transoral surgery 133
Trauma, direct 64
Traumatic spinal cord injury 90
course of 109
different stages of 110
Tricortical iliac bone graft 140
Tuberculosis-polymerase chain reaction 128
Ultrasonic bone scalpel 48, 48f
Upper instrumented vertebra 65
Urinary catheter 61, 82, 101
Urinary problems 72
Urinary retention 3, 82, 101, 102
Urinary tract infections 3, 25, 58, 61
Vaccination status 21
Vascular injury 58
Vena cava, inferior 61, 93
Venous thromboembolism 61
Vertebral artery
injury 133
left 133, 134f
relationship of 134f
Vertebral compression fracture 58
Vertebral fractures 62
Vertebral malformations, congenital 72
Vibratory motion 48
Video consent 109
Visceral damage 73
Visual analog scale 28, 104
Visual disciplines of modern medicine 89
Volume rendering technique 133f
Wake-up test 36
Weight-bearing flexion-extension 47
Whole body, EOS scans of 47f
Whole spine standing antero- posterior 140f
World Health Organization 9
World Health Organization surgical safety 120
Wound complications 100
Wound contamination 132
Wound dehiscence 72, 73, 78
Ziehm imaging© 50
Ziehm vision FD Vario 3-D 5, 50
Chapter Notes

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ASSI Monograph Safe Spine Surgery
ASSI Monograph Safe Spine Surgery
Avoiding Adverse Events and Improving Outcomes
Editors-in-Chief Shankar Acharya MS FRCS (Ortho) MCh (Ortho) Chairman Department of Spine Surgery Consultant Orthopedic and Spine Surgeon Sir Ganga Ram Hospital New Delhi, India Amit Jhala MS DNB (Ortho) Senior Consultant Spine Surgeon Chief and Director Department of Spine Surgery HCG Multispecialty Hospital Ahmedabad, Gujarat, India Associate Editors Amol Rege MS (Ortho) MCh (Ortho) D (Ortho) DNB (Ortho) MSc (Ortho) FRCS (Tr & Ortho) Consultant Spine Surgeon Department of Spine Surgery Deenanath Mangeshkar Hospital and Research Centre Pune, Maharashtra, India Pankaj Kandwal MS (Ortho) Professor, Head and Program Chair Department of Orthopedics All India Institute of Medical Sciences Rishikesh, Uttarakhand, India Foreword Rajiv K Sethi
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Contributors Foreword
Safety in Spine Surgery has made significant strides over the past decade and this positive movement has made the life changing and preserving the gift of spinal surgery available to children and adults in all corners of the globe. It has been my honor to participate vigorously in this movement as we have learned to work in teams, mitigate risk, use new technology and ultimately provide safer and higher quality spinal surgery to our patients. As a spinal deformity surgeon, this resonates with me daily as I care for the most complex adult spinal deformities from all regions of the USA.
The Indian scenario for providing high quality safe spine care, despite limited resources, has taught me a great amount over the past two decades. As a member of the diaspora embodying Indian pride and heritage, I salute the great ideals of our culture which aims to serve people and meet them at their greatest time of need. I have had the privilege and honor of operating with great Indian surgeons in Delhi, Mumbai and Chennai just to name a few. I have had the opportunity to chair two SRS worldwide courses in Ahmedabad and Hyderabad in conjunction with the ASSI annual meeting. Both events focused on safety and value bringing the world's greatest academic spinal surgeons to India from all over the globe.
We have learned that technology is our best friend when it comes to reducing harm to our patients. When this technology helps us plan or perform surgery at a more exact level, it can reduce unplanned return to the operating room. We have learned that high functioning teams outperform the smartest surgeon when the surgeon builds this fortress around himself/herself. Most importantly, we have seen that paying acute attention to the literature around safety in the care of frail adult patients will show tremendous progress in the coming years. Much of the attention in previous years has been focused on the intraoperative phase of care. This might be in pedicle screw design, cage design or in design of enabling technologies like robots and navigation. In the next decade, you will see an equivalent amount of industry, energy being paid to the preoperative phase of care. The concept of optimization of the spine surgical patient will be enhanced by virtual care and predictive analytics resulting in patient-specific prehabilitation and patient-specific surgical plans and implants. The planning of surgery will become more automated and errors will be eliminated by this process. The aviation industry has taught us a great deal about the culture of safety and the need to eliminate variability. This true north will continue to guide thought leaders in safety in spine surgery.
This book is an important effort by the Association of Spine Surgeons of India to educate surgeons and their associated colleagues on the current best practices around safety in spinal surgery. This is a sentinel effort to ensure that patients around India get the best care possible despite limited resources. The COVID-19 pandemic has laid bare the inequalities that many of our fellow humans face on a daily basis. As surgeons and healers, we will have to work even harder to provide access to our life changing procedures that maintain function and movement. Nobody is better suited to lead the way in this work than the spinal surgeons of India.
Jai Hind!
Rajiv K Sethi MD
Clinical Professor and Spinal Surgeon
Department of Spine Surgery
University of Washington
Virginia Mason Medical Center (Neuroscience Institute)
Seattle, WA, USA
Association of Spine Surgeons of India (ASSI) over the last few years has come up with monograms on various topics in Spine Surgery.
These have been well-received and has benefited both students in training and consultants in practice.
In the last decade, spine surgery in India and across the world has seen an exponential growth both in terms of volume, and in technological advances in techniques of spine surgery. Minimizing surgical errors and maximizing patient safety is of paramount importance in the present times.
This monogram entitled Safe Spine Surgery covers a wide spectrum of topics keeping in mind the importance of safety and accuracy in spine surgery.
As President ASSI, it is my privilege and honor to write this for the monogram. I extend my special thanks to Dr Amit Jhala and his Co-Editors Amol Rege and Pankaj Khandwal for bringing out this excellent monogram with contributions from authors across the world.
I am sure all members of the ASSI will find it useful.
Jai Hind!
Shankar Acharya
President ASSI
In past two decades, spine surgery has an exponential growth because of with increased awareness, improvement in understanding, diagnostic technology and development of modern technology for spine surgery. More complex spine surgeries are also being performed which were thought impossible in past with overall improved outcomes of spine surgery. Although the outcomes of spine surgery have improved, spine surgery itself has higher and more disabling complication rates and adverse events during the surgery. These numbers are also affected by the large volumes of spine surgery being done at different centers. There is also a frequent gap in patient expectations and surgeons’ expectations, even after perfectly done procedure in the outcome of spine surgery. This has also increased the medicolegal law suits which are also highest in spine surgery. Hence, it is very important in these modern days to have a “Safe Spine Surgery” by avoiding the adverse events and hence improving the outcomes. The safety applies in spine surgery not only in improving the surgical skills by technology but also goes much more beyond improving the procedural challenges. It involves precision in all the steps of patient care from, decision making, preoperative evaluation, preoperative preparations, patient counseling and education with informed consent of the procedure, meticulous surgical technique with good postoperative care. From admission to discharge there can be numerous sources of errors like administrative errors, nursing and communication between the healthcare providers. The surgery is a team approach by multiple teams of different specialties leading to communication errors between the teams. The spine surgeon requires not only a good surgical skill, but also requires a true leadership quality to coordinate within his team and other departments to make the process of patient care absolutely safe.
This monograph is very important in modern days which deals with all the aspects of improving the safety in spine surgery from surgical checklists, safety protocols, risk stratification and patient counseling, multidisciplinary team approach, insight into modern surgical technology for precision spine surgery, improving the postoperative protocols, improving the nontechnical skills and lastly how to deal with legal aspects in case of complications.
Amit Jhala